New Client Information Form in Leesburg, VA | Old Mill Veterinary Hospital

Client Information

Note: if there is a field not applicable to you, please fill in with N/A.

Date*

Home Phone*

Email*

Owner's Name*

First Last

Owner's Cell Phone*

Spouse/Other

First Last

Spouse/Other Cell Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer

Employer Telephone #

Emergency Contact Person

First Last

Local Telephone #

How did you first hear about us?*

Yellow Pages
Brochure/Mailing
Internet

Is there anyone we can thank?

Patient Information

Species*

Canine
Feline

Name*

Breed*

Color*

DOB (age)*

Sex*

Male
Female

Altered*

yes
No

Distemper*

Rabies*

Other Vax*

Is your pet(s) currently protected against heartworm disease?*

yes
No

Product?

Is your pet(s) currently protected against fleas/ticks?*

yes
No

Product?

I, the undersigned, authorize the veterinarian(s) and staff employed by Old Mill Veterinary Hospital to examine, prescribe for and treat accordingly up to and including medical surgical procedures for the patient/s specifically described and identified above.

I assume responsibility for all charges incurred for services rendered to the patient/s.

Also, I understand payment is due when services are rendered. Deposits may be required for some services.

There are additional fees assessed for non-payment, returned checks and accounts sent to collection. I understand and agree to pay these fees.

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.